Efficacy of Fufang E'jiao Jiang in the Treatment of Patients with Qi and Blood Deficiency Syndrome: A Real-World Prospective Multicenter Study with a Patient Registry

Objective This nationwide, multicenter prospective observational study with a patient registry was designed to evaluate the efficacy of Fufang E'jiao Jiang (FEJ) in Chinese patients with Qi and blood deficiency syndrome (QBDS). Methods QBDS patients were consecutively recruited from 81 investigational sites in China from July, 2019, to December, 2020. Patients who met the eligibility criteria were enrolled in a prospective registry database. Baseline characteristics and changes in scores on the traditional Chinese medicine (TCM) symptom evaluation scale for Qi and blood deficiency, the clinical global impression (CGI) scale, the fatigue scale-14 (FS-14), and the Pittsburgh sleep quality index (PSQI) were analyzed to determine the clinical efficacy of FEJ. Results A total of 3,203 patients were recruited. The average remission rate (i.e., the sum of the cure rate and improvement rate) of the 20 symptoms of QBDS was 92.49% after 4 weeks of FEJ treatment, which was higher than at baseline; the rate increased to 94.69% at 8 weeks. The CGI scale revealed that the number of total remissions at 4 and 8 weeks was 3,120 (97.41%) and 415 (100%), respectively. The total FS-14 scores decreased by 1.67 ± 4.11 (p < 0.001) at 4 weeks and 1.72 ± 3.09 (p < 0.001) at 8 weeks of treatment. The PSQI scores were 6.6 ± 4.7 and 6.52 ± 3.07 at 4 and 8 weeks, respectively, which were significantly lower than the baseline scores (p < 0.001; p = 0.0033). Both the subhealth fatigue (SF) and iron deficiency anemia (IDA) groups showed significantly improved clinical symptoms of QBDS (p < 0.01). Between-group comparisons revealed significantly greater improvements in FS-14 and PSQI scores in the SF group than in the IDA group (p < 0.05). A multivariate logistic regression analysis showed that disease course, FS-14 score at baseline, and four-week FEJ doses were independent risk factors for the degree of symptom relief in QBDS patients (p < 0.05). Conclusion In real-world settings, FEJ has a promising effect in treating QBDS and can significantly improve the severity of its symptoms.


Introduction
Qi and blood defciency is a concept in the theory of traditional Chinese medicine (TCM) that refers to the defciency of Qi in the organism or the diminished function of Qi combined with a blood defciency that makes the organs and tissues lose the nourishment of Qi and blood, resulting in the corresponding weakening disease [1]. Te main clinical manifestations of Qi and blood defciency are dizziness, weakness, spontaneous sweating, shortage of Qi, slurred speech, pallor, palpitations, and insomnia [2]. Qi and blood defciency syndrome (QBDS) is mainly seen in patients with chronic diseases such as anemia, leukopenia, and malignant tumors. Epidemiological studies show that approximately 75% of the global population is considered to be subhealthy, and healthy and ill people account for 5%, and 20% of the remaining individuals, respectively [3]. In China, healthy and ill people each account for 15% of the population, and subhealthy people account for 70%, which encompasses more than 900 million individuals [4]. Although subhealth does not cause organic pathology in the short term, it does seriously afect quality of life. Without proper intervention, it may increase the risk of diabetes, cardiovascular and cerebrovascular diseases, cancer, and other diseases [5].
Tere are no efective treatment modalities for subhealth states [6]. For anemia and leukopenia caused by radiotherapy for malignant tumors, treatment is usually carried out by iron supplementation, blood transfusion, hematopoietic stem cell migration, and immunosuppression subsequent to certain treatments, but the treatment efcacy is unstable, and those conditions easily relapse. Moreover, there are many side efects from these treatments [7][8][9][10][11].
Fufang E'jiao Jiang (FEJ) is a patented Chinese medicine that has been marketed in China to replenish Qi and nourish blood, and it has been approved by the China Food and Drug Administration (CFDA). FEJ is a Chinese herbal compound preparation composed of Ejiao (Asini Corii Colla), red ginseng, Radix Rehmanniae, Radix Codonopsis pilosula, and Hawthorn, of which Asini Corii Colla is the primary active ingredient [12]. It is mainly used to treat dizziness, palpitations, insomnia, poor appetite, leukopenia, and anemia caused by defciency of Qi and blood [13][14][15][16][17][18]. However, there are few real-world studies on using FEJ for treating QBDS, and there are also no real-world studies on using FEJ in China or Asia. Terefore, we targeted our survey to the FEJ market with the aim of further exploring the potential clinical value of the prescription by observing the actual application and efcacy of FEJ marketed in a real-world setting.

Study Design.
Tis is a multicenter, prospective, singlearm, observational real-world case study with a patient registry. From July, 2019, to December, 2020, this study recruited patients with QBDS from 81 study sites (including 19 hospitals, 35 pharmacies, 17 outpatient clinics, and 10 community medical service centers) in 6 cities in China (including Anhui, Beijing, Jiangsu, Henan, Shandong, and Shanghai). Te study was conducted in accordance with the ethical principles of the Declaration of Helsinki and in accordance with good clinical practice guidelines and applicable local regulatory requirements. Te trial protocol was approved by the Ethics Committee of Xiyuan Hospital, China Academy of Chinese Medicine Sciences (2019XLA027-2), which was accepted by the primary study site and all other centers. It was also registered with the Chinese Clinical Trials Registry (ChiCTR1900025328). Tis study is reported following the guidelines for the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [19] (Supplementary Table 1).
FEJ, as used in the study, was the product of Shandong Dong-E-E-Jiao Co., Ltd. (Shandong, China) with batch No. Z20083345. Te ingredients used in the preparation of FEJ include Asini Corii Colla, red ginseng, Radix Rehmanniae, Radix Codonopsis pilosula, and hawthorn. Te standard dose of FEJ was 20 ml. Te reference dosing regimen is one tablet per dose, administered orally three times daily. Adjusting the dosing regimen (reduction or increase in frequency and quantity) and discontinuing the drug is at the patient's discretion.

Participants.
Patients who met the inclusion and exclusion criteria were consecutively recruited at the registration site. Te inclusion criteria were as follows: meeting the TCM diagnostic criteria for QBDS [20] (Supplementary  Table 2), taking FEJ, and agreeing to participate in the study. Te exclusion criteria were as follows: contraindications to FEJ, such as allergy to FEJ or any excipients; participation in other clinical trials; and refusal to follow-up. We conveyed the details of this study to all participants at each study center. Patients who met the eligibility criteria were prospectively registered on the network (Electronic Data Capture, EDC). All enrolled patients or their authorized guardians signed an informed consent form before participation. Some selection bias may have accompanied patient selection of involvement, but we did not arbitrarily select patients. All patient details were deidentifed simultaneously.

Data
Collection. All data, including age, sex, clinical characteristics, symptom remission, concomitant diseases, and concomitant medications, were collected using an online mobile platform. All centers collected data according to our institution's uniform prespecifed protocols. In addition, an EDC system was constructed for this project. Data are collected at each center, recorded on a case report form (CRF), and entered into the clinical trial EDC system by specially trained staf.
Patients in this study received FEJ according to local practice and the best interests of individuals. Consistent with the true observational nature of the study, patients included in the study were not involved in any treatment decisions because they were treated without any additional protocols. Te treatment choice had to be made before the patient was enrolled in the study. Patients were enrolled and completed follow-up information as needed, which the researcher collected after 4 weeks of treatment. After completing the 4week scheduled course of treatment, patients could voluntarily continue to complete an additional follow-up survey on WeChat if they continued to receive therapy to monitor the long-term benefts of the real-world application of FEJ. Treatment information was voluntarily completed by the patient and collected by a research assistant at week 8.
Te corresponding information was collected at each follow-up visit (Supplementary Table 3). It was used to assess the changes in the TCM symptom evaluation scale of Qi and blood defciency, the clinical global impression (CGI), the fatigue scale-14 , and the Pittsburgh sleep quality index (PSQI) scores before and after treatment with FEJ.

Outcome Measurement.
According to the "Guidelines for Clinical Research on New Chinese Medicines" [21], the TCM symptom evaluation scale for Qi and blood defciency was used to evaluate the improvement of symptoms, including forgetfulness, jaundiced appearance, pallor, slurred speech, shortage of Qi, dizziness, pale mouth and lips, lassitude of spirit, pale nail color, pale eyelids, blurred vision, shortness of breath, lack of strength, spontaneous perspiration, palpitations, menstrual irregularities (any abnormalities in the menstrual cycle, volume, and color), insomnia, limb numbness, and excessive dreaming caused by Qi and blood defciency. Te evaluation of TCM symptoms was divided into 4 grades: cured, improved, no relief, and deteriorated. Te CGI scale [22] is a global assessment of the patient's physical health during treatment. Te scale has 7 levels: signifcant deterioration, moderate deterioration, mild deterioration, no remission, mild remission, signifcant remission, and complete remission. Te FS-14 [23] is used to evaluate physical and mental fatigue syndrome. Tis scale is mainly composed of 14 items divided into two categories: categories 1-8 include 8 items refecting physical fatigue and categories 9-14 consist of 6 items refecting mental fatigue. Te maximum score is 14 points, and higher scores indicate more severe fatigue. Te PSQI [24] was used to assess sleep quality and quantity. Te scale contains 19 items across 7 factors. Each factor is scored from 0 to 3, with a total score of 0 to 21. A higher score indicates poorer sleep quality.

Statistical Analysis.
Continuous variables are expressed as the mean ± standard deviation (SD) or median with interquartile range (IQR) values. Confdence intervals (CI) are given when necessary. Categorical variables were expressed as frequencies or percentages. Descriptive analyses were performed to summarize patient, disease, and treatment characteristics. For the assessment of changes in the FS-14 and the PSQI from enrollment to the study's predefned follow-up time points, paired t tests or Wilcoxon rank sum tests were used. Te mean ± SD and p values were calculated for paired data. For comparisons between the SF and IDA groups, the independent samples t test or Mann-Whitney U test was used for quantitative data, and the chi-square test was used for categorical data. Considering the inconsistent baseline levels between the subhealth fatigue (SF) and iron defciency anemia (IDA) groups, a comparison of FS-14 scores and PSQI scores between the two groups was performed using a general linear model (analysis of covariance) to calibrate the inconsistent baseline variables between the groups (p < 0.05). A multivariate logistic regression analysis with CGI scale symptom relief as the dependent variable was developed to analyze the risk factors afecting the degree of relief in QBDS patients. Two-sided statistical tests were used for all analyses. p < 0.05 was considered a statistically signifcant diference. Statistical analyses were performed using SAS (version 9.4).

Patient Demographics and Baseline Characteristics.
A total of 4,521 patients were registered during enrollment. Te efcacy analysis group included 3,203 patients. A total of 1,318 patients were excluded: 853 individuals did not provide full visit records and 462 were lost to followup. All patients (n = 3203) who entered the efcacy analysis completed the 4-weekfollow-up. Of these patients, 415 (12.96%) voluntarily completed the 8weekfollow-up ( Figure 1).
Te study included a high proportion of SF and IDA disease diagnoses in QBDS patients, with 2,459 (76.77%) and 713 (22.26%), respectively. Te remaining disease diagnoses accounted for less than 3% of the cases, and the small amount of data may lead to unreliable analysis results. Terefore, we stratifed the analysis for SF and IDA only. Analysis of the baseline data between the two groups showed that the duration of disease, number of Qi and blood defciency TCM symptoms, baseline FS-14 score, and baseline PSQI score were signifcantly lower in the SF group than in the IDA group (p < 0.05). Tere were no signifcant diferences between the two groups in terms of gender and age (p > 0.05). Tese results are shown in Table 3.

Dosing Statistics.
Te total number of doses taken from baseline to the end of the fourth week of treatment was counted. Te results showed that at week four, the total number of doses taken by the patient was 48 (48, 90). At week eight, the total number of doses was 96 (96, 192). Te number of doses taken at eight weeks was twice as high as that taken at four weeks.

Efect of FEJ on TCM Symptoms of Qi and Blood
Defciency. After 4 weeks of treatment with FEJ, 3,203 patients were evaluated with the TCM symptom evaluation scale for Qi and blood defciency; the average remission rate (remission rate is the sum of the cure rate and improvement rate) of the 20 symptoms of Qi and blood defciency was 92.49%, and 18 symptoms had a remission rate of more than 90%. Among them, the remission rates of lassitude of spirit (95.48%) and dizziness (95.32%) exceeded 95%. At the 8th week, the average remission rate was 94.69%. Te remission rate of 19 symptoms exceeded 90%, including 10 symptoms with a remission rate of more than 95%. Te remission rates of lassitude of spirit and menstrual irregularities were as high as 99.33% and 98.31%, respectively (Table 4).

Evaluation Results of the CGI Scale after FEJ Treatment.
After 4 weeks of treatment with FEJ, 3,203 patients were evaluated with the CGI scale. Te total number of remissions reached 3,120 (97.41%), of which 14.39% of the patients had completely relieved their symptoms and 58.48% had achieved signifcant subjective relief. A total of 24.54% of patients experienced mild relief of symptoms. A total of 2.47% of patients felt that their symptoms were not relieved and 0.12% of patients experienced deterioration in their symptoms (2 cases with mild deterioration, 1 case with moderate deterioration, and 1 case with signifcant deterioration). At week 8, all 415 patients felt that their symptoms were in remission, and 59.52% felt that their symptoms had completely resolved. Tere were no reports of worsening symptoms (Figure 2).

Univariate and Multivariate Analyses of the Outcome of QBDS Patients after FEJ Treatment.
Logistic univariate analysis showed that age, disease course, FS-14 score at baseline, and four-week FEJ doses were associated with the degree of symptom relief in patients with QBDS (p < 0.05). Furthermore, multivariate logistic analysis was performed on the diferent indicators in the univariate analysis. Te results showed that duration of illness, FS-14 score at baseline, and four-week FEJ doses were independent risk factors for the degree of symptom remission in patients with QBDS (p < 0.05) (Tables 5 and 6).   Table 5).

Comparison of Clinical Remission Rates between the SF and IDA Groups.
Te CGI scale assessment showed that after four weeks of FEJ treatment, total remission reached 2,172 (97.40%) in the SF group and 479 (97.96%) in the IDA group, with no signifcant diference in the total remission rate between the two groups (p > 0.05) ( Table 7).

Comparison of FS-14 Scores between the SF and IDA
Groups. Patients in the SF and IDA groups had signifcantly lower FS-14 total scores and scores on all dimensions compared to baseline (p < 0.01). An analysis of covariance was applied to calibrate the baseline disease duration, number of TCM symptoms of Qi and blood defciency, baseline FS-14 scores, and baseline PSQI scores between the SF and IDA groups and then to compare the FS-14 scores between the two groups at four weeks. Te results showed that compared to the IDA group, the SF group showed a greater improvement in all dimensions, with the total FS-14 score and physical fatigue dimension score being signifcantly lower than the IDA group (p < 0.01). In contrast, the mental fatigue dimension score diference was not statistically signifcant (p > 0.05) ( Table 8).

Comparison of PSQI Scores between the SF and IDA
Groups. Te total PSQI score and the fve dimensions of sleep duration, subjective sleep quality, use of sleeping medication, and sleep disturbance were signifcantly lower at four weeks of FEJ treatment than at baseline in both the SF and IDA groups (p < 0.01). Te habitual sleep efciency dimension was only improved in the SF group compared to the baseline (p < 0.01). Te sleep latency dimension was signifcantly improved only in the IDA group compared to the baseline (p < 0.01). Tere was no signifcant reduction in daytime dysfunction dimension scores in either group compared to baseline (p > 0.05). Variables that were not homogeneous between the two groups were calibrated to compare the diference in PSQI scores between the two groups at four weeks. Te results showed that the SF group had a signifcantly greater reduction in total PSQI scores and habitual sleep efciency dimension scores than the IDA group (p < 0.05). However, no signifcant diferences were found between the two groups in other dimensions at four weeks (p > 0.05) ( Table 9).

Discussion
In our study, the CGI scale assessment showed that the number of patients with some symptoms in remission after 4 weeks of treatment with FEJ was 3,120 (97.41%), of which 14.39% were in complete remission. At the 8th week, the number of patients with some symptoms in remission was 415 (100%), of which 59.52% were in complete remission, an increase from the 4th week. At the 4th week of follow-up, the average remission rate of the 20 symptoms of Qi and blood defciency was 92.49%, which increased to 94.69% at the 8th week. Te remission rate gradually increased for two possible reasons: (1) the extended treatment period allowed the FEJ to reach its full efcacy and (2) most patients who adhered to the medication for 8 weeks may have had some improvement at 4 weeks.
Te antifatigue efect of FEJ was confrmed in our study. Te study showed a continuous decline in total scores on the FS-14 and PSQI scales at four and eight weeks after FEJ treatment. However, the scores on each dimension fuctuated more at eight weeks. Sleep and fatigue are infuenced by   Evidence-Based Complementary and Alternative Medicine multiple factors, such as daily activities, life environment, and socioeconomic status [25][26][27][28]. Moreover, the patients' follow-up data at the 8th week were reported voluntarily, and we could not know the patients' medication background. Terefore, the data source was not controllable, leading to unreliable results at 8 weeks.    In our study, 76.77% (2,459 cases) of patients were diagnosed with SF. SF is one of the most common types of subhealth, with fatigue as its most prominent manifestation [29]. However, we have not found relevant clinical research evidence on treating SF with FEJ. However, a study on the treatment of women with QBDS with FEJ [30] showed that the brightness of the tongue was reduced, and the color of the tongue and the tongue image improved signifcantly after treatment with FEJ. It is suggested that FEJ can play a certain therapeutic role in the population with QBDS. Tis is consistent with the results of our study.
After four weeks of FEJ treatment, patients in the SF and IDA groups showed a signifcant improvement in symptoms, FS-14 scores, and PSQI scores compared to baseline. Te SF group showed a signifcant reduction in FS-14 and PSQI scores compared to the IDA group. Te diferences in the baseline disease course, number of symptoms of Qi and blood defciency, and baseline FS-14 score were more signifcant between the two groups. In addition, the results of logistic regression analysis in this study showed that disease course, FS-14 score at baseline, and four-week FEJ doses were independent factors afecting the efcacy of FEJ on QBDS. Terefore, we adjusted for inconsistent variables at baseline by analysis of covariance to minimize the efect of confounding factors between the groups.
IDA is the most common form of nutritional anemia and is the ultimate manifestation of iron defciency in the body, afecting over 1.2 billion people [31]. Te symptoms of fatigue in people with IDA are caused by iron defciency in the brain tissue and are classifed as disease fatigue [32]. Terefore, recovery from symptoms is afected by the recovery of ferritin. Recent studies have reported that iron supplementation may take several weeks (>6 weeks) to show complete improvement in fatigue, lethargy, and sleep in IDA patients [33,34]. Terefore, some experts recommend assessing ferritin response 6-12 weeks after starting oral iron in stable patients without signifcant anemia [35]. However, SF is not usually abnormal in terms of physiological indicators connected upstream to health and downstream to disease. Terefore, the weaker improvement in fatigue and sleep in the IDA group than in the SF group at four weeks may be related to the shorter follow-up period. It still needs to be determined whether the tonic and blood-generating efects of FEJ will afect the hemoglobin of IDA patients. One study showed [36] that the combination of FEJ signifcantly improved erythrocytes, hemoglobin, and hematocrit in patients with postpartum anemia compared to iron sucrose alone. Terefore, we recommend the combined use of FEJ and iron supplements in IDA patients to correct iron defciency and improve symptoms in a shorter time frame.
Te observation period of this study was relatively short. However, at the 4th week of follow-up, patients showed a signifcant improvement in symptoms, indicating that FEJ has a fast onset of action. In the real world, after accounting for factors such as socioeconomics, it is difcult for most patients to adhere to long-term treatment plans. In contrast, FEJ can improve patients' clinical symptoms in a short period, giving FEJ real-world relevance. Second, this study applied the EDC system to record the clinical data of patients. Te data collection and recording process are rigorous and scientifc, thereby reducing information bias in realworld research. In addition, the results of clinical studies may not always accurately predict real-world outcomes because of limitations such as strict eligibility criteria and unintentional bias produced by the selected study center. Terefore, these observational studies based on patient registration data can well refect real-world data nationwide and demonstrate the efectiveness of FEJ, thus providing signifcant research value.

Limitations.
Tere are some limitations in our study. First, this study was observational and did not have a control group, which may have led to selection bias. However, we used continuous recruitment to recruit study participants, thereby minimizing selection bias. Second, the patients voluntarily completed the follow-up information at 8 weeks. Most patients who continued to take the drug for 8 weeks likely achieved some efcacy at 4 weeks. Terefore, the assessment of remission rates at 8 weeks may be biased. In addition, the study results may be infuenced by confounding factors, such as diet and concomitant medications.

Conclusions
Overall, the results of this multicenter, prospective, singlearm, observational study represents the frst real-world study of FEJ in China. Te study showed that treatment with FEJ efectively improved the clinical symptoms of patients with QBDS.

FEJ:
Fufang E'jiao Jiang QBDS: Qi and blood defciency syndrome TCM: Traditional Chinese medicine CGI: Clinical global impression FS-14: Fatigue scale-14 PSQI: Pittsburgh sleep quality index CFDA: China Food and Drug Administration ChiCTR: Chinese Clinical Trials Registry STROBE: Strengthening the Reporting of Observational Studies in Epidemiology ECD: Electronic data capture CRF: Case report form IQR: Interquartile range SD: Standard deviations SF: Subhealth fatigue IDA: Iron defciency anemia.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that there are no conficts of interest regarding the publication of this study.